Antipsychotics for Dementia: CMS Says Use Less

Medicare and Medicaid say antipsychotics are still used too often on nursing home dementia units.

The Centers for Medicare & Medicaid Services (CMS) and other healthcare organizations are aiming to have use of antipsychotics among dementia patients decreased by 30% in the next 2 years.

"We know that many of the diagnoses in nursing home residents do not merit antipsychotics but they were being used anyway," Patrick Conway, MD, deputy administrator for innovation and quality and the CMS chief medical officer, said in a press release issued late last week. "In partnership with key stakeholders, we have set ambitious goals to reduce use of antipsychotics because there are -- for many people with dementia -- behavioral and other approaches to provide this care more effectively and safely."

The release noted that between the end of 2011 and the end of 2013, "the national prevalence of antipsychotic use in long-stay nursing home residents was reduced by 15.1%, decreasing from 23.8% to 20.2% nationwide. The National Partnership is now working with nursing homes to reduce that rate even further."

Leonard Gelman, MD, CMD, president of the board of directors of the American Medical Directors Association, an organization for nursing home medical directors that is part of the partnership, praised the new goal. "I'm happy any time someone discusses decreasing inappropriate medications," said Gelman, of Ballston Spa, N.Y.

He added that the 25% goal was not unreasonable, especially since "we've already done 15%. And don't forget it's a percent of a percent, so it's not as drastic as it looks." Since the rate is already at around 20%, "if you're reducing [that amount] by 10%, it's only going down by 2% total."

Reducing antipsychotics is part of a larger approach on nonpharmacologic treatment for these patients, according to Gelman. "In general, this is one of things we've been internally talking about, and also talking with CMS and others," he said. "There are many instances where medications can be reduced, not just antipsychotics -- certainly benzodiazepines, also blood pressure medications and cholesterol medications."

Many people think that most of the medications nursing home patients take have been prescribed by the nursing homes, but that's not the case, Gelman pointed out. "They get prescribed in the hospital [or by the patient's primary care physician]. In essence, the nursing home doctors rarely prescribe these things, but we continue them for many different reasons, unfortunately. It's a merry-go-round that keeps going 'round and 'round but it's difficult to push the horse off the merry-go-round, because everyone has told the family and the patients they need [the medications]."

When dementia patients get to a stage where they become very agitated, "people are looking ... for an easy fix. So these medications are used," even though in many cases they don't help," Gelman continued. On the other hand, "the things we know work the best are most difficult logistically, and that is, essentially, having someone be with the patient ... all the time."

Short of that, caregivers and families "can try to understand what the patient is like, and what they liked before and what they didn't like, their activities, their food preferences -- all these things to individualize the care of the patient. Their basic personality doesn't change, and you can work towards that."

CMS said it's going to keep track of what happens once the antipsychotics will reduced, such as by "review[ing] prescriptions of anxiolytics and sedative/hypnotics to make sure nursing homes do not just replace antipsychotics with other drugs. In addition, CMS will review the cases of residents whose antipsychotics are withdrawn to make sure they don't suffer an unnecessary decline in functional or cognitive status as a nursing home tries to reduce its usage."

The agency also released a fact sheet with state-by-state data on antipsychotic reductions. States varied in how much they reduced use of these medications over a 21-month period ending with the first quarter of 2014 -- Hawaii reduced use in that state by 31.4%, while Nevada reduced antipsychotic use by 1.6%.

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